EMC I understand that if I do not check any of the boxes below, my authorized representative will be authorized to perform all of the . CDSS forms and publications are available only in Portable Document Format (PDF). endstream endobj 891 0 obj <>/Subtype/Form/Type/XObject>> stream Box 12941, Oakland, CA 94604. N')].uJr 0 Generally, only a patient may authorize release of his/her medical information. Gathering information is vital for every type of transaction in any organization. A Financial Authorization Form is also used by business men in allowing their trusted representatives to transact an amount on their behalf. EMC Form processing may be delayed if fields with an asterisk are not filled out. 0 Record the representative's name and address on the AREP screen in ACES. Follow the step-by-step instructions below to design your cal fresh authorized representative form: Select the document you want to sign and click Upload. Dental, Request for Access to Protected Health Information. Here's How, CW 2184 (8/16) - CalWORKS 48-month Time Limit, CW 2184 (4/21) - CalWORKs 60-Month Time Limit, CW 2186A (12/12) - CalWORKs Exemption Request Form, CW 2186A (4/21) - CalWORKs Exemption Request Form, CW 2186B (4/21) - CalWORKs Exemption Determination, CW 2187 (4/11) - Your CalWORKs 48-Month Time Limit, CW 2187 (4/21) - Your CalWORKs 60-Month Time Limit, CW 2188 (4/02) - Verification Of Aid For The Temporary Assistance For Needy Families (TANF) Program, CW 2189 (3/15) - Notice of Your CalWORKs Time Limit - 42th Month On Aid, CW 2189B (9/20) - Notice Of Your CalWORKs Time Limit 57TH Month On Aid (Use Starting May 1, 2022), CW 2190A (4/21) - CalWORKs 60-Month Time Limit Extender Request Form, CW 2190B (5/16) - CalWORKs 48-Month Time Limit Extender Determination Denial Form, CW 2190B (4/21) - CalWORKs 60-Month Time Limit Extender Determination Form, CW 2191 (4/21) - Time On Aid Verification For CalWORKs/TANF 60-Month Time Limits, CW 2192 (4/21) - Tracking Non-California TANF Assistance For Time Limits, CW 2200 (5/22) - Request For Verification, CW 2200LP (6/19) - Request For Verification, CW 2201 (6/09) - Unemployment Insurance Benefits Referral Form, CW 2203 (11/09) - Request For Supplemental Payment By Check Or Direct Deposit, CW 2208 (2/13) - Your Welfare-To-Work 24-Month Time Clock, CW 2209 (12/14) - Immunization Good Cause Request Form, CW 2211 (11/14) - Your CalWORKs Reporting Rules Have Changed, CW 2212 (11/14) - The Rules For Your CalWORKs Case Have Change, CW 2213 (10/15) - Response To Request To Inspect Case Record CalWORKs, CalFresh, TCVAP, And Refugee Programs, CW 2215 (10/20) - California Work Opportunity and Responsibility to Kids (CalWORKs) Important Information for Safety Net And Certain Child-Only Case, CW 2217 (1/15) - CalWORKs Request For Voluntary Repayment, CW 2218 (7/19) - Rights, Responsibilities And Other Important Information For The California Work Opportunity And Responsibility To Kids (CalWORKs) Program (Non-Needy Caretaker Relative With Relative Foster Child), CW 2218 (6/21) - Rights, Responsibilities And Other Important Information For The California Work Opportunity And Responsibility To Kids (CalWORKs) Program (Non-Needy Caretaker Relative With Relative Foster Child), CW 2218 (3/22) - Rights, Responsibilities And Other Important Information For The California Work Opportunity And Responsibility To Kids (CalWORKs) Program (Non-Needy Caretaker Relative With Relative Foster Child), CW 2219 (5/16) - Application For California Work Opportunity And Responsibility To Kids (CalWORKs) (Non-Needy Caretaker Relative With Relative Foster Child), CW 2223 (9/18) - Demographic Questionnaire For CalWORKs, Refugee Cash Assistance (RCA), Entrance Cash Assistance (ECA), Trafficking And Crime Victims Assistance Program (TCVAP) And CalFresh Programs, CW 2224 (6/19) - CalWORKs Home Visiting Initiative (HVI), DFA 377.1A (3/02) - Notice Of Denial Or Pending Status, DFA 377.7A (4/21) - Notice Of Administrative Disqualification, DFA 377.7D2 (10/00) - Food Stamp Repayment Notice for Administrative Errors Only, Final Notice, DFA 377.7E (7/04) - Food Stamp Repayment Agreement For Administrative Errors Only, DFA 377.7F (6/18) - CalFresh Overissuance Notice - Intentional Program Violation (IPV), DFA 377.7F LP (6/18) - CalFresh Overissuance Notice - Intentional Program Violation (IPV), DFA 377.7F1 (10/00) - Food Stamp Repayment Notice for an Intentional Program Violation (IPV) Only, Final Notice, DFA 377.7G (5/02) - Food Stamp Repayment Agreement For An Intentional Program Violation (IPV) Only, DFA 377.10 (6/04) - Food Stamp Notice Of Disqualification, DFA 377.11B (11/00) - Food Stamp Notice Of Continuance, DPA 19 (6/22) - Appointment OfAuthorized Representative, DPA 315 (7/99) - Withdrawal/Conditional Withdrawals Of Request For Hearing, DPA 435 (1/18) - County Allegation Of Intentional Program Violation/Statement Of Position (Request For An Administrative Disqualification Hearing), DPA 436B (8/18) - County Information Letter, DPA 479 (12/17) - Administrative Disqualification Hearing Waiver - CalWORKs/CalFresh, EBT 1232 (6/22) - CalFresh Notice Of Action - EBT Account, EBT 2216 (10/22) - EBT Surcharge Free - Direct Deposit Handout, EBT 2259 (1/23) - Report Of Electronic Theft Of Benefits, EBT 2259A (11/21) - EBT Scamming Acknowledgement, EBT 2260 (8/21) - Excessive Card Replacement Warning Letter, EFA 7 (7/21) - The Emergency Food Assistance Program (TEFAP) Certification Of Eligibility, EFA 7A (BI) (3/11) - Emergency Food Assistance Program (EFAP) Certification Of Eligibility, EFA 14 (3/23) - The Emergency Food Assistance Program (TEFAP) 2023Income Guidelines, EFA 15 (3/23) - Alternate Pick-Up Request Form The Emergency Food Assistance Program (TEFAP) 2023Income Guidelines, FC 2 NM (2/12) - Statement of Facts Supporting Eligibility For AFDC-Extended Foster Care (EFC). endstream endobj 232 0 obj <> stream }3$@JAt " ]YL /@ > Al hacer clic en el botn Aceptar, acepta el uso de estas tecnologas y el procesamiento de tus datos para estos propsitos. Please refer to the EBT Manual for more information. Review these documents as they have important information regarding your application. The followingforms are informationalonlyanddo not need to bereturned to the county. I understand that I may receive a copy of this authorization. Medical professionals, financing agents, employers, and even faculty members need to submit a ReleaseAuthorization Formto allow themselves toaccess the information of a particular person. An AREP can be any adult who is not a member of the AU who is sufficiently aware of the household circumstances and is authorized by the household to act on behalf of the client for eligibility purposes. /Tx BMC This form authorizes the release of medical information to the representative . Educational Institutions. endstream endobj 893 0 obj <>/Subtype/Form/Type/XObject>> stream Building partnerships and connections through outreach, giving, and volunteering. Authorized Representative Name: Authorized Representative Address: Authorized Representative Telephone Number: I authorize the above designated individual to act as my representative for the purposes checked below. "J@B+$)5@h(-4:H.HHr=0ZP2,Ea qt)4/F.z For information regarding AREP for Long-Term Care cases see: Long-Term Care AREP or WAC -Long-Term Care for Families and Children. la persona asignada para el proceso de legalizacin en los distintos Ministerios, Cmaras, Consulados y Organismo Oficiales que requiera, con ms de 20 aos de experiencia Contamos tambin con traductores Jurados reconocidos por el Ministerio de Asuntos Exteriores, 2022 Apostilladodelahaya.comTodos los derechos reservados, 2022 Apostilladodelahaya.com Todos los derechos reservados. xcbd```b```r5&H2&[k`XW Yq,DH D The Authorizing Individual. EMC endstream endobj 962 0 obj <>/Metadata 32 0 R/Pages 959 0 R/StructTreeRoot 67 0 R/Type/Catalog/ViewerPreferences<>>> endobj 963 0 obj <>/MediaBox[0 0 612 792]/Parent 959 0 R/Resources 986 0 R/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 964 0 obj <>stream wG xR^[ochg`>b$*~ :Eb~,m,-,Y*6X[F=3Y~d tizf6~`{v.Ng#{}}jc1X6fm;'_9 r:8q:O:8uJqnv=MmR 4 H\Pj0+t=,G([ AD 931 (2/20) - Independent Adoption Of A Foreign-Born Child - Statement Of Acknowledgment. %PDF-1.7 % Cal program to send the CSF 14 to applicants/beneficiaries to appoint a Medi-Cal AR? An AREP can share any information relevant to eligibility; however, the department can only share information with the AREP that is necessary for the purposes of determining financial eligibility. The patient or legally authorized representative must sign and date the form. STATEOFCALIFORNIA-HEALTHANDHUMANSERVICESAGENCY CALIFORNIADEPARTMENTOFSOCIALSERVICES. The Alameda County Social Services Agency provides resources and opportunities in a culturally responsive manner to enhance the quality of life in our community by protecting, educating, and empowering individuals and families. AD 4320 (6/22) - Adoption Assistance Program (AAP) Agreement . Choose My Signature. Photocopies of this authorization shall be considered as valid as an original. Delete coded AREP information if you can'tconfirm with the client that it's still valid. There are times when we can share confidential client data without the client's permission: To learn more about when it is permissible to share client information please refer to DSHS Administrative Policy 5.02, Section D;4. The following forms need to becompleted duringfortheCalFreshapplication and renewal processes. f8EN*ZY\?PQH~>}vfy*2`V6]k=_Oh5p|0 t6?2fS.\v4 `c9-rf;(T3:5I_d81Xuowf'dzG6_`EpC#b@FC>@M\4f+xTK9s/)-xL);P H^t-$?Lo)17?R|osx?t81x{e4RlP])[Y>. Edit your calfresh release of information form online. HIPAA restrictions prevent us from discussing the client's individual health information with an AREP unless a current signed DSHS 14-012(x) consent form is in the record. p()md). H\Mj0>37"),CFq}0 TO BE COMPLETED BY APPLICANT / BENEFICIARY . /Tx BMC 4. We help individuals, families, and communities access services and public benefits that make a difference in their lives. xcbd```b``V}`r5dXWd +D2)H "0012d[20j?cS&.@~{ h! xc```c``#0``B]{20t8. When it's permissible to share information without consent. HTP=o ',V58)RC!C}MH g?=FoaF3i uP`{zT8u8@JsaSu+n7"k03h-.+AA5t2/+Rz3>&3n'!0N-@0 NiA@}n9r?%# AD 4324 (2/21) - Adoption Questionnaire I This is a large PDF file. {=:^zu*EQ `mm:HZ2B dIB,bV@@iE @}r:H:2utsb"tt#SIw$ 'Gb'!1.!H]`-T 140 0 obj <> endobj Both the client and Alternate Card Holder must complete and sign the DSHS 27-130 form. 886 0 obj <> endobj 936 0 obj <>/Filter/FlateDecode/ID[(\326\207Z2N\272\261I\266\305#\003b\307\005+) (\306o\226_\362i\tK\273\200\262\254> stream This chapter defines an authorized representative (AREP) and provides instruction on: What form to use in order to code someone in ACES or the ECR as an AREP. 222 0 obj <> endobj 291 0 obj <>/Filter/FlateDecode/ID[('\315mre\3113.\033X\030>\fU\216\257) (Ruz\246o\3345M\225\321\256\261D\027\337\\)]/Index[222 70]/Info 219 0 R/Length 114/Prev 267957/Root 223 0 R/Size 292/Type/XRef/W[1 3 1]>> stream Here's How, CW 2166 (4/21) - Multilingual Work Really Pays! n3kGz=[==B0FX'+tG,}/Hh8mW2p[AiAN#8$X?AKHI{!7. 269 0 obj <>stream Clients can makechanges to an AREP's information, such as address or phone numberverbally but wemustclearlydocument these changes in the case record. AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION & APPOINTMENT OF REPRESENTATIVE HBEX 403 (07/17) Page 2 Consumer Authorization By my signature, I hereby authorize Covered California, to release the following personal information to the individual or entity identified below: Name of Individual or Entity: Street Address: City and State: Zip Code: its regulations and nQt}MA0alSx k&^>0|>_',G! %%EOF AUTHORIZED REPRESENTATIVE,20. Esta web utiliza cookies propias y de terceros para su correcto funcionamiento y para fines analticos. endstream endobj 897 0 obj <> stream Purpose: This chapter defines an authorized representative (AREP) and provides instruction on: What form to use in order to code someone in ACES or the ECR as an AREP. Student Financial Aid Verification CSF 50 (English and Spanish) Additional Forms. Form . Printable blank application forms for all our services. I understand that if I do not check any of the boxes below, my authorized representative will be authorized to perform all of the . C-761 Bay Area Consortium CAPI Transmittal, 50-85A Language Preference Form Cover Sheet (multi-language), 50-85 Language Preference Form (multi-language), C-134 Cash Assistance Program for Immigrants (CAPI) General Eligibility Information, Payment Levels and Reporting Responsibilities, 20-02 You May Be Required to Apply for SSI, SSP 14 Authorization for Reimbursement of Interim AssistanceChinese,Spanish, SOC 453 CAPI Statement of Household Expenses and ContributionsChinese,Spanish, SOC 455 CAPI State Interim Assistance Reimbursement AuthorizationChinese, Spanish, SOC 809 CAPI Indigence Exception StatementChinese, Spanish. Problems with downloading forms? AD 100A (7/20) - Authorization For Release, Use And/Or Disclosure Of Health Information AD 165 (3/15) - Presumed Father's Consent To Adoption When Denying He Is The Biological Father (In Or Out-Of-California) - Independent Adoptions Program apes chapter 4 quizlet multiple choice. SECTION I. lx}I=u1\=VrN!F\UlRpDRhO|#s9c^l~3e;12qCqB*.3P-J=*S=+OeD^_ ,rZ EMC Hln0z;PJkK"D6~9)a'Gf4OcH|.jDry6vn[U)}SpwS[ Pn?%9:t 14-532 Authorized Representative Author: Brombacher, Millie A. 63-57 CalFresh Application Cover Sheet (multi-language), CW 2223 Demographic QuestionnaireChinese, Spanish, 50-110 Voter Preference FormCambodian, Chinese, Farsi, Spanish, Tagalog,Vietnamese. EMC %%EOF The name, address, contact numbers, and date of birth are the common information found on this section. AnEmployment Authorization Formshould be signed by the employee to allow the employer in viewing his information and do a reference check from his previous company. Uncategorized. Release of Information . El asesor que se le asignar tendr una comunicacin directa desde el principio hasta el final de su gestin y entrega.La persona asignada para el proceso de Apostilla en los distintos Ministerios, Cmaras, Colegios y Organismo Oficiales que requiera, con ms de 20 aos de experiencia Contamos tambin con traductores Jurados reconocidos por el Ministerio de Asuntos Exteriores, Nuestro personal est altamente cualificado. "F$H:R!zFQd?r9\A&GrQhE]a4zBgE#H *B=0HIpp0MxJ$D1D, VKYdE"EI2EBGt4MzNr!YK ?%_&#(0J:EAiQ(()WT6U@P+!~mDe!hh/']B/?a0nhF!X8kc&5S6lIa2cKMA!E#dV(kel }}Cq9 NOTE: Some links on this page are documents in Adobe . csf 14 authorization for release of information authorized representative. 2y.-;!KZ ^i"L0- @8(r;q7Ly&Qq4j|9 Third Party Liability Notification. An AREP can receive letters, including the income computation sheet, renewal forms, and ProviderOne services cards if the client has authorized the sharing of such correspondence. endstream endobj 68 0 obj <>>>/Filter/Standard/Length 128/O(! Title 22 of the . csf 14 authorization for release of information authorized representative. H\0 hb```"oV)af`0p &I0nafX4AD?P`YJD!NMV$2F3{i1 032p040060`}Pht@/ABo].T.`FY?R~04\.zd'&?Jl| @ H/M 257 0 obj <>/Filter/FlateDecode/ID[<2C3F7BAF13469A49B4F374642767AFD6>]/Index[234 36]/Info 233 0 R/Length 106/Prev 161226/Root 235 0 R/Size 270/Type/XRef/W[1 3 1]>>stream The AREP information shall be reviewed at recertification. Tips for Using Adobe PDF Files. When to require the DSHS 17-063 authorization form or HCA 80-020 authorization for the release of information form. 9L $? U csf 14 authorization for release of information authorized representative. 1B114F All Forms N/A Authorization for Release of Information Authorized Representative CSF 14 506481 Reason Code County Category NOA Action Document Name Number Template 300001 Placer Forms Affidavit to N/A Obtain Duplicate Warrant All 662 609763 300001 Santa Barbara Forms N/A Affidavit to Obtain Duplicate of Lost or The records of a students grades and transcript from the previous university will be disclosed with the aid of a Transcript Release Authorization Form. endstream endobj 234 0 obj <> stream H|n@,SEKlp5i"o93vtEew~iyL7{l4MW_jpymf_y>qli|?O]0w2GlH6tyW?wKYX~bcdo9gL[^KQ (m6 K%%@IX Legal Guardianship is designated by coding the AREP screen Rep Type field in ACES with the following: Power of Attorney for cash, medical, and basic food is designated by coding the AREP screen Rep Type field in ACES with AD or NA. The following forms need to be completed during the application process. csf 14 authorization for release of information authorized representative. 4pIe^8 /;$GOj^y%^.N.ycq:9;dRs);a;I&,d0m2.erHe9eeMiB z 4K[}{5hp~8S=P8 ngB[pNrP-=*|?p0;n%]5KY{ endstream endobj 231 0 obj <> stream Notable exceptions to the rule are as follows: a. 1034 0 obj <>stream SAWS 2 Plus:Application forCalFresh, Cash Aid, and/or Medi-CalCambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, Other languages, CF 285: Application for CalFresh BenefitsCambodian, Chinese,Farsi,Spanish,Tagalog, Vietnamese, Other languages, CF 37: Recertificationfor CalFresh BenefitsCambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, Other languages, CCFRM604: State of California Health Insurance ApplicationCambodian,Chinese, Farsi, Spanish,Tagalog,Vietnamese, Other languages, 90-16:Application for General Assistance, SOC 814:Statement of Facts Cash Assistance Program for Immigrants (CAPI)Chinese, Spanish, Other languages, 90-152:GA Accomodation RequestSpanish,Cambodian,Chinese,Farsi,Vietnamese, SAR 7:Eligibility Status ReportCambodian, Chinese, Farsi, Spanish,Tagalog,Vietnamese,Other languages, SAR 3: Mid-Period Status Report For Cash Aid and CalFreshCambodian, Chinese,Farsi, Spanish,Tagalog,Vietnamese,Other languages, CalWORKs, CalFresh, Refugee Cash Assistance, and General AssistanceCSF 14: Authorization for Release of Information - Authorized Representative, Medi-CalMC 382: Appointment of Authorized RepresentativeCambodian,Chinese,Farsi,Spanish,Tagalog,Vietnamese, MC 383: Authorized Representative Standard Agreement for Organizations, CAPIC-776:CAPI Authorized Representative Form.
